MEDICAL-LEGAL ISSUES IN QUALITY ASSURANCE
Quality assurance is defined as an evaluation of the conditions under which care is provided. Quality assurance, which is also known as "quality improvement" or "quality assessment" may be applied in the hospital, in the medical office setting, at a health maintenance organization (HMO) or at a preferred provided organization (PPO). Quality assurance involves the identification of a problem, the determination of the source and nature of the problem, an assessment on how to effect improvement in the situation, the design of policies for remedying the problem through appropriate methods, and implementation of those policies and monitoring of the methods applied to see if they have been effective. Quality assurance monitoring of policy may be done on a individual case-by-case basis or system-wide.
Doctors and other licensed providers apply to the medical staff of a hospital, HMO or PPO for an initial appointment and every two years must submit a reappointment application. The hospital, HMO or PPO has the responsibility of checking the accuracy and completeness of the application; of contacting references, the state medical board, the National Practitioner Data Bank; of confirming the status of board eligibility or certification; and of investigating in some fashion pending claims, settlements or judgments against the practitioner to determine their seriousness. Through its medical staff bylaws most hospitals have the means of disciplining, reducing privileges, monitoring or dismissing from its membership doctors who seriously and/or repeatedly deviate from the standard of care or who deviate from norms of doctor-patient behavior.
Similar provisions are in the bylaws of HMOs and PPOs, although exclusion of a doctor can be done without a fair hearing and without cause in these organizations.
Failure to Implement Existing Policy:
Incidents in hospitals tend to occur over and over again so that in time hospitals write policy to avoid the recurrence of such incidents. Policy derives from quality assurance activities.
Falls are common especially in the elderly and confused patient during the first day of stay. Most hospitals have specific, step-by-step, fall prevention policies in which the individual likely to be susceptible to a fall is identified by certain key characteristics. Measures are then taken to prevent the fall from occurring. Nursing staff should be familiar with these policies and in the nursing assessment identify the fall-prone patient and implement the policy.
The housing of a patient in an area of the hospital not conductive to safe confinement is a breach of most hospital policies about patient safety. Placing an intoxicated, delusional or suicidal patient on the second or high floor, in a room with windows and screens that allow access to the outside, carries the risk of the patient harming him/her self.
There are many architectural requirements that should be followed in the design of a psychiatric unit or chemical dependency unit. Use of fixtures such as shower curtain rods that do not break away at low weight stress can lead to hanging. The failure to suspect and search for sharp objects on a closed psychiatric unit is a breach of care by the facility. The failure to have an emergency medical response capability by a free-standing psychiatric unit (that is not physically part of a general hospital) can lead to unnecessary delay in the treatment of life-threatening illness or complications from neuroleptic medications or other conditions.
Fires are easily preventable. A patient who is not capable of properly lighting or extinguishing a match or cigarette should not have access to flammable materials.
Protocols do exist about pre-operative testing and the means of stopping or postponing the scheduled procedure by the nurse in charge of the operating room should there by a significant fallout on pre-operative testing, such as an abnormal electrocardiogram or laboratory study that might reflect a serious underlying process. These protocols insure that a patient going in for elective or event urgent surgery is not subjected to anesthesia or the rigors of surgery and its accompanying post-operative physiological changes without a medical assessment first to determine whether the body is capable of withstanding the intended surgery, whether the surgery will be complicated by an underlying medical condition or whether there is not another more serious medical problem that needs to be addrerssed before the surgical procedure. Too ofter, however, the pre-operative checklist is ignored and surgery goes forth without regard to the presence of a complicating or more serious pre-existing condition.
Timely Referral and Treatment:
A delay in referral to an emergency room or to the appropriate consultant by a free-standing HMO or by a staff model HMO owed by the insurer can lead to delay or failure to diagnosis and treat. The HMO will or should have policy for treating emergencies, often published in their handbooks for members, in which the usual route of referral may be overridden in the event of an emergency. Failure of the administrative physician or nurse on call to direct the patient who presents with an obvious or suspected emergency to the appropriate best resources and to bypass the primary care physician gatekeeper represents a deviation from the standard of care.
Proper and Timely Notification of Results:
A CAT scan read by the on-call radiologist at the request of the emergency room doctor as showing a subdural hematoma; an electrocardiogram interpreted in the emergency room as normal but actually seriously abnormal in the opinion of the reading cardiologist; a mammogram ordered by the family practitioner and read that week by the radiologist as showing a mass needing further investigation. All these are examples of positive findings that need to by conveyed back as soon as possible to the treating primary care physician and for which there must be a fail-safe means of ensuring that the communication loop will always be a closed loop. Most referring and reading physicians have policy of some kind for follow-up or abnormal testing results. Still, some do not, or some have faulty policy that invites mistakes and a few have policy but do not use it correctly.